Sowmya R. Rao

Use of electronic health records in U.S. hospitals.

BACKGROUND Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals. METHODS We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption. RESULTS On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems. CONCLUSIONS The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.

Electronic Health Records’ Limited Successes Suggest More Targeted Uses

Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated

False discovery rate control is a recommended alternative to Bonferroni-type adjustments in health studies.

20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.

Alcohol consumption and cardiovascular mortality among U.S. adults, 1987 to 2002.

OBJECTIVES Procedures for controlling the false positive rate when performing many hypothesis tests are commonplace in health and medical studies. Such procedures, most notably the Bonferroni adjustment, suffer from the problem that error rate control cannot be localized to individual tests, and that these procedures do not distinguish between exploratory and/or data-driven testing vs. hypothesis-driven testing. Instead, procedures derived from limiting false discovery rates may be a more appealing method to control error rates in multiple tests. STUDY DESIGN AND SETTING Controlling the false positive rate can lead to philosophical inconsistencies that can negatively impact the practice of reporting statistically significant findings. We demonstrate that the false discovery rate approach can overcome these inconsistencies and illustrate its benefit through an application to two recent health studies. RESULTS The false discovery rate approach is more powerful than methods like the Bonferroni procedure that control false positive rates. Controlling the false discovery rate in a study that arguably consisted of scientifically driven hypotheses found nearly as many significant results as without any adjustment, whereas the Bonferroni procedure found no significant results. CONCLUSION Although still unfamiliar to many health researchers, the use of false discovery rate control in the context of multiple testing can provide a solid basis for drawing conclusions about statistical significance.

Electronic health records in small physician practices: availability, use, and perceived benefits

OBJECTIVES The aim of this study was to determine the association of alcohol consumption and cardiovascular mortality in the U.S. population. BACKGROUND Alcohol consumption has been associated with a lower risk of cardiovascular disease in cohort studies, but this association has not been prospectively examined in large, detailed, representative samples of the U.S. population. METHODS We analyzed 9 iterations of the National Health Interview Survey, an annual survey of a nationally representative sample of U.S. adults between 1987 and 2000. Exposures of interest included usual volume, frequency, and quantity of alcohol consumption and binge drinking. Mortality was ascertained through linkage to the National Death Index through 2002. Relative risks were derived from random-effects meta-analyses of weighted, multivariable-adjusted hazard ratios for cardiovascular mortality from individual survey administrations. RESULTS Light and moderate volumes of alcohol consumption were inversely associated with cardiovascular mortality. Compared with lifetime abstainers, summary relative risks were 0.95 (95% confidence interval [CI]: 0.88 to 1.02) among lifetime infrequent drinkers, 1.02 (95% CI: 0.94 to 1.11) among former drinkers, 0.69 (95% CI: 0.59 to 0.82) among light drinkers, 0.62 (95% CI: 0.50 to 0.77) among moderate drinkers, and 0.95 (95% CI: 0.82 to 1.10) among heavy drinkers. The magnitude of lower risk was similar in subgroups of sex, age, or baseline health status. There was no simple relation of drinking pattern with risk, but risk was consistently higher among those who consumed >or=3 compared with 2 drinks/drinking day. CONCLUSIONS In 9 nationally representative samples of U.S. adults, light and moderate alcohol consumption were inversely associated with CVD mortality, even when compared with lifetime abstainers, but consumption above recommended limits was not.

Physician professionalism and changes in physician-industry relationships from 2004 to 2009.

OBJECTIVE To examine variation in the adoption of electronic health record (EHR) functionalities and their use patterns, barriers to adoption, and perceived benefits by physician practice size. DESIGN Mailed survey of a nationally representative random sample of practicing physicians identified from the Physician Masterfile of the American Medical Association. Measurements We measured, stratified by practice size: (1) availability of EHR functionalities, (2) functionality use, (3) barriers to the adoption and use of EHR, and (4) impact of the EHR on the practice and quality of patient care. RESULTS With a response rate of 62%, we found that < 2% of physicians in solo or two-physician (small) practices reported a fully functional EHR and 5% reported a basic EHR compared with 13% of physicians from 11+ group (largest group) practices with a fully functional system and 26% with a basic system. Between groups, a 21-46% difference in specific functionalities available was reported. Among adopters there were moderate to large differences in the use of the EHR systems. Financial barriers were more likely to be reported by smaller practices, along with concerns about future obsolescence. These differences were sizable (13-16%) and statistically significant (p < 0.001). All adopters reported similar benefits. Limitations Although we have adjusted for response bias, influences may still exist. CONCLUSION Our study found that physicians in small practices have lower levels of EHR adoption and that these providers were less likely to use these systems. Ensuring that unique barriers are addressed will be critical to the widespread meaningful use of EHR systems among small practices.

Need for speed: Evaluating slopes of OCD recovery in behavior therapy enhanced with d-cycloserine

BACKGROUND One tenet of medical professionalism is managing conflicts of interest related to physician-industry relationships (PIRs). Since 2004 much has been done at the institutional, state, and national levels to limit PIRs. This study estimates the nature, extent, consequences, and changes in PIRs nationally. METHODS We performed a national survey of a stratified random sample of 2938 primary care physicians (internal medicine, family practice, and pediatrics) and specialists (cardiology, general surgery, psychiatry, and anesthesiology). A total of 1891 physicians completed the survey, yielding an overall response rate of 64.4%. The main outcome measure was prevalence of several types of PIRs and comparison with PIRs in 2004. RESULTS Overall, 83.8% of all respondents reported some type of relationship with industry during the previous year. Approximately two-thirds (63.8%) received drug samples, 70.6% food and beverages, 18.3% reimbursements, and 14.1% payments for professional services. Since 2004 the percentage of each of these benefits has decreased significantly. Higher rates of PIRs are significantly and inversely associated with low levels of Medicare spending. CONCLUSION Among a random sample of physicians, the prevalence of self-reported PIRs in 2009 was 83.8%, which was lower than in 2004.

Pre‐travel Health Advice‐Seeking Behavior Among US International Travelers Departing From Boston Logan International Airport

Evidence suggests that the antibiotic d-cycloserine (DCS) enhances the treatment effects of exposure and response prevention (ERP) for Obsessive-Compulsive Disorder (OCD). Further, evidence suggests that the effects of DCS diminish partway through treatment, but it is unclear to what extent. In an effort to evaluate these issues, the current study re-analyzes data from a 10-session randomized controlled trial of ERP+DCS versus ERP+placebo in a sample of 22 adults with OCD. We analyzed repeated-measures mixed models with random slopes and intercepts across different intervals: sessions 1-10, 1-5, and 6-10. The results indicate that the course of ERP was 2.3 times faster over the full 10 sessions for the DCS compared to the placebo group, and nearly six times quicker in the first half of ERP. Further interpretation of the results suggests that DCS does not amplify the effects of ERP, but instead initiates treatment effects sooner in treatment. In addition, DCS does not necessarily lose its effect over repeated use, but instead may exhaust its maximum utility after effectively jump-starting ERP. Ultimately, DCS may provide a means for curtailing treatment costs, decreasing treatment dropout and refusal rates, and enhancing access to care.

Food insufficiency and health services utilization in a national sample of homeless adults.

BACKGROUND Globally mobile populations are at higher risk of acquiring geographically restricted infections and may play a role in the international spread of infectious diseases. Despite this, data about sources of health information used by international travelers are limited. METHODS We surveyed 1,254 travelers embarking from Boston Logan International Airport regarding sources of health information. We focused our analysis on travelers to low or low-middle income (LLMI) countries, as defined by the World Bank 2009 World Development Report. RESULTS A total of 476 survey respondents were traveling to LLMI countries. Compared with travelers to upper-middle or high income (UMHI) countries, travelers to LLMI countries were younger, more likely to be foreign-born, and more frequently reported visiting family as the purpose of their trip. Prior to their trips, 46% of these travelers did not pursue health information of any type. In a multivariate analysis, being foreign-born, traveling alone, traveling for less than 14 days, and traveling for vacation each predicted a higher odds of not pursuing health information among travelers to LLMI countries. The most commonly cited reason for not pursuing health information was a lack of concern about health problems related to the trip. Among travelers to LLMI countries who did pursue health information, the internet was the most common source, followed by primary care practitioners. Less than a third of travelers to LLMI countries who sought health information visited a travel medicine specialist. CONCLUSIONS In our study, 46% of travelers to LLMI countries did not seek health advice prior to their trip, largely due to a lack of concern about health issues related to travel. Among travelers who sought medical advice, the internet and primary care providers were the most common sources of information. These results suggest the need for health outreach and education programs targeted at travelers and primary care practitioners.

Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey

BACKGROUNDHomeless people have high rates of hospitalization and emergency department (ED) use. Obtaining adequate food is a common concern among homeless people and may influence health care utilization.OBJECTIVEWe tested the hypothesis that food insufficiency is related to higher rates of hospitalization and ED use in a national sample of homeless adults.DESIGNWe analyzed data from the 2003 Health Care for the Homeless (HCH) User Survey.PARTICIPANTSParticipants were 966 adults surveyed at 79 HCH clinic sites throughout the US. The study sample was representative of over 436,000 HCH clinic users nationally.MEASURESWe determined the prevalence and characteristics of food insufficiency among respondents. Using multivariable logistic regression, we examined the association between food insufficiency and four past-year acute health services utilization outcomes: (1) hospitalization for any reason, (2) psychiatric hospitalization, (3) any ED use, and (4) high ED use (≥4 visits).RESULTSOverall, 25% of respondents reported food insufficiency. Among them, 68% went a whole day without eating in the past month. Chronically homeless (p = 0.01) and traumatically victimized (p = 0.001) respondents were more likely to be food insufficient. In multivariable analyses, food insufficiency was associated with significantly greater odds of hospitalization for any reason (AOR 1.59, 95% CI 1.07, 2.36), psychiatric hospitalization (AOR 3.12, 95% CI 1.73, 5.62), and high ED utilization (AOR 2.83, 95% CI 1.32, 6.08).CONCLUSIONSOne-fourth of homeless adults in this national survey were food insufficient, and this was associated with increased odds of acute health services utilization. Addressing the adverse health services utilization patterns of homeless adults will require attention to the social circumstances that may contribute to this issue.